Documentation Crucial for OT Interventions in Autistic Children

16-October-2014 Julie Clements Medical Transcription

Different occupational therapy (OT) interventions including physical activities, play activities, developmental activities and adaptive activities can help autistic children perform better in school and home environments. However, occupational therapists should keep their documentation accurate, comprehensive and complete to ensure appropriate and effective therapy services. Such kind of documentation can communicate information regarding the client from the OT perspective, reflect the occupational therapists’ clinical reasoning and professional judgment and client response to OT interventions so that it will be easier to find out opportunities for improvement and make the therapy effective.

According to the American Occupational Therapy Association (AOTA), occupational therapists evaluate autistic children using observation as well as both parent and teacher reports while creating an intervention plan. They will also conduct interviews with parents regarding their child’s relationships and eating, daily living skills and self care. Furthermore, they work with families and teachers as a team to manage the most immediate and important issues. The therapists actually align families, teachers and other service providers in their therapy which help in the academic success of children with autism. In order to make this collaboration successful, therapists should document all the information (for example, communication, visual skills, daily living skills) about the children gathered from these interactions accurately and completely. With this, the therapists can support the parents and help them to be more effective in providing care for their children.

The documentation elements for the intervention process as per the AOTA guidelines are as follows.

Intervention Plan – The intervention goals, intervention approaches and types of interventions to be used, service delivery details, discharge plan, outcome measures (assessment of occupational performance), details of professionals overseeing the plan and date of plan are documented here.
Contact Report Note – This section documents the contacts between the patient and the therapist which include the types of interventions used as well as the patient’s responses including telephone contacts, interventions and meeting with others.
Progress Report/Note – This section includes the summary of the intervention process along with the brief statement of services provided. It also includes the patient’s progress towards the treatment goals, new data gathered, modifications to the treatment plan and statement of need for continuation, discontinuation, or referral.
Transition Plan – This section documents the formal transition plan (name of current service setting, name of setting to which the patient will be transferred, reason for transition, time frame of transition and outline of activities carried out during the transition plan) along with the patient’s current status and recommendations. This is written when a patient is transferred from one service setting to another within a service delivery system.

Therapists should document their reports according to the payer, facility and federal guidelines. Electronic health records (EHRs) are quite effective in managing all documentation elements for therapists. Even so, the electronic system may sometimes lack completeness and accuracy owing to the templates that limit narration. Moreover, errors may occur inadvertently when copy pasting content hastily to save time. With the help of professional transcriptionists and Discrete Reportable Transcription (DRT) technology, it is possible to populate relevant EHR fields with more complete and accurate information transcribed from the therapists’ dictation.

Teledermatology Improving Health Outcomes and Reach

14-October-2014 MTS TEAM Medical Transcription

The American Academy of Dermatology (AAD) defines teledermatology as the remote delivery of dermatological services and clinical information with the help of telecommunication technology. There are two types of modalities in this health care model – ‘Store-and-forward’ in which digital images and associated patient data are sent and forward to the specialist for storage and consultation, and ‘Live-interactive’ in which providers and patients interact through live video using a variety of peripheral hardware attachments to enhance the consultation. So the telemedicine model allows patients to send details and interact directly with the dermatologist and enables physicians to send patient information to a dermatologist and interact directly with the specialist for consultation or triage. Let’s take a closer look at how this health care model is improving health outcomes and rich.

Major Benefits of Teledermatology

As per the American Association of Telemedicine, teledermatology is one of the most active telemedicine applications in the United States and is helping dermatologists to extend their reach to patients in a cost-effective manner. A recent study published in JAMA Journal reveals that this health care model is proving a reliable mechanism for the triage of inpatient dermatology consultations and can enhance efficiency by enhancing access to specialized care for hospitalized patients. Healthcare experts perceive three main benefits for this model over traditional visits:

Better Communication – In the traditional office visit, a patient normally has a 5 to 15 minute consultation with the dermatologist and most of the instructions for the treatment and helpful skincare advice given is immediately forgotten. This gap is often filled by the pharmacist or by the patient browsing the Internet or calling up the physician. E-consultation enables the specialist to provide a detailed analysis of the diagnosis, treatment instructions, and a specific plan to follow (on-demand resources) which can be accessed by patients from their smartphone or computer at any time. This model allows patients to message their dermatologist about their condition along with necessary images instead of self-diagnosing side-effects or reactions to the treatment. Patients thus experience a sense of continuity in their consult with the specialist.

Efficient Measurement – In online consultation, patients can upload photos of their skin during the first consultation and also for each follow-up. This consistent and visual documentation of the patient’s condition makes online diagnosis more efficient than that in a traditional office setting. Evaluating the patient’s before and after photos would allow the dermatologist to see how their condition has improved so that immediate feedback can be provided on the progress of the treatment. If the dermatologist sees many patients each day, they may not specifically remember what the patient originally looked like in case of a follow-up visit. They usually rely on their charts and notes, which obviously do not measure up to the crucial information provided by the quality close-up images of the affected area that the patient sends.

Easy Access – A 2001 study showed that around 42% of Americans live in areas underserved by a dermatologist. The AAD also sees a shortage of dermatologists in general and has published a map that highlights underserved areas. Teledermatology is the best alternative to render dermatological services and information to these areas. This system allows anyone with smartphone or computer to access care through online consultations and enables low-risk conditions to be treated online. Another major benefit is that it supports both asynchronus (not simultaneous, for example, e-mail) and synchronus (simultaneous, for example, Skype call) care. In synchronus care, a call has to be scheduled in advance so that the physician is free and ready to participate in the conversation. At the same, the physician can respond at a time that best fits their schedule in case of asynchronus care. Dermatologists can treat their patients as best fits their work flow with this type of care and fill excess capacity with a pending online consultation for diagnosis and treatment

Crucial Role of EMR

Clinical documentation can be quite challenging in the context of providing health care services to patients in remote areas. Electronic Medical Records (EMRs) play a crucial role in managing this issue. The standard point-and-click technology with EMR makes it easy for the dermatologist to enter patient details collected at the time of online consultation into the computer. They can browse through the available choice of clinical terms and click on the appropriate one to generate the medical record in electronic format. Once the electronic record is created, they can easily retrieve the requisite data from their computer at either time during the online consultation. This quick and easy access improves the quality of the patient care and reduces operational costs as well. If the EMR is integrated with teledermatology through wireless technology, it will become quite easy to treat and diagnose patients living in remote areas. A good EMR offers the following benefits:

Captures complete patient health details and customizes the data
Provides clinical decision support
Enables complete patient charting
Manages patient scan/images
Allows patients to access their medical information online
Allows doctors to share medical information with specialists at distant places

EMR allows data entry in various ways – via keyboards/mouse/touch screens (for primary patient data including diagnosis, patient history and findings), camera (for video signal transfer), speech-to-recognition systems, and transcription. Integrating EMR with transcription by professional transcriptionists can produce documentation that is much more accurate than point-and-click and speech recognition technologies. Transcribed teledermatology reports integrated with EMR can greatly enhance the online consultation process.

Tips to Optimize Telecare

Remote dermatological consultations should be performed on a HIPAA compliant web-based platform. The success of this health care model depends on the ability of the healthcare provider to establish authentic relationships with patients, the proper definition of quality care in the telemedicine environment, and the availability of the requisite technology to make it work. Healthcare experts have put forward the following conditions to optimize the quality of online care:

Make out a medical problem with a diagnostic data set so that it can be acquired by the patient/consumer in easy and reliable manner
Ensure that the patient understands that the online consultation is problem-specific and may carry risks such as omitting care that involves other health issues
Assure the patient that the treatment decisions for a specific condition are algorithmic and do not need an authentic relationship

Physical Therapy Less Costly Than Shots for Shoulder Pain

13-October-2014 Rajeev Rajagopal Physical Therapy Transcription

According to a recent study conducted in a military hospital-based outpatient clinic in the United States, physical therapy (PT) is a less costly option than corticosteroid injection (CSI) for shoulder impingement syndrome (SIS), though both work equally well. The participants of the study included 104 patients aged 18 to 65 years having unilateral SIS between June 2010 and March 2012. Patients who don’t like injections will obviously choose PT as an effective option. Physical therapists treating patients with shoulder pain will have to focus on their documentation related to physical therapy provided to improve patient outcome and satisfaction.

For the study, 104 patients were divided into two groups, those receiving 40-mg triamcinolone acetonide subacromial CSI and those receiving 6 sessions of manual PT. While the change in shoulder pain and disability index scores at 1 year was the primary outcome, secondary outcomes included the Global Rating of Change scores, the Numeric Pain Rating Scale scores and one year healthcare use. The study results showed approximately 50% improvement in Shoulder Pain and Disability Index scores for both groups. There were improvements in Global Rating of Change scale and pain rating scores for both groups as well. However, the significant finding is that CSI group had more SIS-related visits to their primary care provider (60% vs. 37%) and needed additional steroid injections (38% vs. 20%) during the 1 year follow-up.

The additional visits to the primary care provider indicate that there is a persistent problem. The study showed that the CSI group used more healthcare services and had significantly more shoulder-related visits compared to the PT group. It also says that 19% of CSI group needed PT also. This clearly indicates that patients receiving injections need to pay more than those who opted for physical therapy.

It is time for physical therapists to fine tune their practices in the backdrop of this study. They should not only ask the right questions about the nature of the pain, the aggravating and relieving factors during the assessment session before the treatment, but also document all these details accurately in a legible manner. It is also required to record the results of special tests that help to determine the structure causing the pain. Unless there is sufficient information available about the initial evaluation, it is not possible to provide quality care and improve practice outcomes.

Adult Survivors of Pediatric Cancer Prone to Health Risks

09-October-2014 MTS TEAM Diseases and Conditions

Pediatric Cancer It is estimated that childhood cancer forms less than 1% of all cancers diagnosed every year. According to the American Cancer Society, a lot of progress has been made in treating pediatric cancer. Long-term survival is now expected of most children diagnosed with cancer, thanks to modern medicine. However, studies show that adult survivors of childhood cancer are prone to serious health risks. Many studies associate the health risks with the consequences of past cancer treatments (for example, radiation and chemotherapy).

A 2013 study by St. Jude Children’s Research Hospital which involved a group of adults diagnosed with cancer about 25 years ago found 98% of participants had at least one chronic health condition including new cancers, lung problems, heart problems or memory or other neurocognitive problems. As the age increased, the risks appeared to increase as well and by age 45 around 80% of participants had at least a single life-threatening, serious or disabling condition. A 2014 study by Denmark researchers revealed that adult survivors of childhood cancer are at high risk of endocrine disorders. It was found that childhood cancer survivors are more likely to have had contact with hospitals for endocrine disorders than others.

Healthcare experts suggest that adults who had cancer as children should get regular medical screening for cancer as well as other conditions in order to identify health problems as early as possible so that it is easier to treat them. Family practice physicians have a great role to play in recommending appropriate tests and advice for these people. They should thoroughly examine the previous medical records that describe the treatments and drugs given for cancer, encourage follow-up visits and ask the patients to maintain a healthy diet and get enough exercise. Physicians should refer the patients to specialists if they find early symptoms of chronic conditions and transcribe the consultation reports accurately. This will help maintain all vital patient details that are required to understand the patient’s condition better.

Advancements in cancer treatment today help ensure that children being treated for cancer receive only less toxic doses of radiation and chemotherapy that can cause serious side effects. However, it is still important to encourage routine-checkups and discuss possible long-term complications with the child’s health with the primary care physicians and specialists. There must be accurate clinical documentation as well so that it is easier for both physicians and specialists to study the current and future complications and devise plans to address them effectively.

Blows to the Head May Cause Brain White Matter Changes Even Without Concussion

07-October-2014 MTS TEAM Medical Transcription

Researchers have found that repeated blows to the heads of athletes may be associated with changes in brain white matter, and may also be linked to reduced cognition even if those impacts do not cause concussion. A study on athletes involved in contact sports vs. athletes participating in noncontact sports over a season revealed a small increase in diffusivity in the white matter. Contact sports athletes performed poorly than expected in cognition tests at the end of the season and had larger changes in brain white matter.

The study involved 80 non-concussed varsity football and ice hockey players who wore helmets that could record the acceleration time history of the head just after the impact, and 79 non–contact sport athletes. The researchers assessed both groups before the season and shortly after the season using diffusion tensor imaging and neurocognitive measures. The contact athletes were engaged at intense level, playing football or ice hockey 5 or 6 times in a week. These players could have sustained around 500 to 600 impacts over a season.

The data obtained through this analysis showed small, but critical differences in the brain white matter between the contact and non-contact athletes. The important findings were:

Measures of head impact exposure did associate with matter diffusivity measures in various brain regions such as corpus callosum, thalamus, cerebellar white matter, hippocampus and amygdale.

The magnitude of change in the corpus callosum revealed the diffusivity after the season was associated with worse performance on a measure of verbal learning and memory.

No difference was observed between the contact and noncontact athletes at the beginning of the season which suggested that no cumulative changes occurred over years of sustaining head impacts.

However, the researchers could not find out the exact reason why one blow caused concussion in one person while a similar blow does not cause concussion at a different time or in a different person. The next step of the study will be to find out how long these changes will sustain and identify whether there exists a subgroup with higher vulnerability and its cause.

Studies such as the above can have a great impact on finding new ways for maintaining a healthy brain. The data collected during these studies may include audio resources which will have to be accurately transcribed. In the above mentioned study, data on two different cohorts of athletes, two different time points and biomechanical exposure and cognition was collected, which may have required a lot of medical transcription work. Researches related to neurology should be accurately documented and the data managed efficiently either by good transcription services in neurology or good documentation via an EMR.

KY Nurse Practitioners’ Prescribing Authority Expanded

29-September-2014 Rajeev Rajagopal Healthcare News

On February 26, 2014, Kentucky Governor Steve Beshear signed into law Senate Bill 7 (SB7), expanding the prescribing authority of Advanced Practice Registered Nurses (APRNs) in Kentucky. The law puts a program in place to allow KY nurse practitioners to collaborate with practicing physicians to prescribe non-scheduled legend drugs. It also allows ARPNs to prescribe routine medications independently if they have been prescribing with a collaborative agreement under the supervision of a physician for four years in the state or have been prescribing routine medication for at least four years in another state either independently or under a collaborative agreement.

The passage of SB7 offers several benefits:

The law is expected to resolve the problem of provider shortage in Kentucky. More and more people are entering the regular health care system with Obamacare and the expansion of Medicaid. These newly insured people will be looking for primary and preventive care services, even as more than 70% of Kentucky counties have partial or full designation as primary care Health Professional Shortage Areas (HPSA). The new law can address this primary care physician shortage and the projected shortfall by offering flexibility to nurse practitioners. It allows more consumers to access the primary care provided by these practitioners.
Also, by permitting independent prescribing by ARPNs, the new legislation will improve the access to high-quality primary care and medications including antibiotics, insulin, cholesterol, anti-hypertension and diabetes medicines.

Though ARPNs are allowed to independently prescribe routine medications, they are not able to prescribe controlled substances without a collaborative agreement under the new law.

The major problem with drug prescriptions is medication errors, which can have fatal consequences and result in costly law suits for health care practitioners. So when the prescribing authority expands, nurse practitioners need to be wary of making medication errors. Prescription of drugs requires knowledge of diagnosis, interactions and contradictions and a technical component including the communication of critical information such the name of the drug, dosage, and form of administration. As the provision of independent prescribing is given for nurse practitioners who have been prescribing under a collaborative agreement for at least four years, they can manage the first part better. It is in the second part that errors are likely to happen. Health care experts point out the following reasons for medication errors:

Illegible or poor handwriting
Use of dangerous abbreviations
Trailing zero after a decimal point while writing the dosage (can lead to 10-fold medication error, for example – 1.0 mg misinterpreted as 10 mg)
Not writing the purpose of the medication
Inadequate contact information for the pharmacist

Accurate transcription of medication histories are an important factor when it comes to preventing prescription errors. In addition to preventing mistakes in prescription, error-free medication histories are also useful in identifying drug-related pathology or changes in clinical symptoms that could result from drug therapy.

As more consumers depend on nurse practitioners owing to the shortfall of primary care physicians, they would benefit by relying on a professional medical transcription service to prevent inadvertent errors and proper documentation of medication history with all prescribed drugs, previous adverse drug reactions, over-the counter medications, and adherence to medication and therapy.

CDC Reports Rise in EHR Adoption Among Office-based Physicians

25-September-2014 MTS TEAM EHR Transcription

The US healthcare system is undergoing a massive transformation as paper-based medical charts give way to electronic health records (EHR). After nearly 25 years of using paper charts, physicians have widely started accepting the use of Electronic Health Records (EHR). A new report from The Centers for Disease Control and Prevention (CDC) states that the EHR adoption among office-based doctors has registered an increase to 78 percent in 2013 when compared to just 35 percent in 2007. The new findings are based on the National Ambulatory Medical Care Survey, which the CDC sends to non-federal, office-based physicians across the country.

The widespread adoption of Electronic Health Records (EHR) is expected to improve the quality of health care while reducing total healthcare costs. With the transition to the digitized record system, hospitals and physicians can provide more information to patients, reduce mistakes, and prevent hospital readmissions.

The increased rate of adoption of EHR technology has been the result of the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The HITECH Act authorized federal incentive programs to healthcare providers for the “meaningful use” of EHRs. The prospect of a five-year Medicaid or Medicare bonus contributed significantly towards the rapid implementation of this technology. The federal incentive program backed by the Centers for Medicare & Medicaid Services has certainly generated wide scope and interest in implementing EHR particularly among primary care physicians as the number of primary care doctors utilizing this technology reported a huge increase in the year 2010.

However, the transition in to EMR is equal among practitioners. According to the CDC’s report, about 40% of practices use the software for recording basic things such as recording patient histories and records, patient demographics and maintaining records of patient tests and prescriptions. Only 23.5% had fully functional software with the ability to order tests and send prescriptions electronically. Also, hospitals have been quicker in adopting Electronic health records than physician’s offices.

Medical practices that fail to comply with federal requirements and demonstrate such ‘meaningful use’ by the end of 2015 will face increasing penalties on their Medicaid and Medicare payments.

Though electronic health records have several advantages, implementation poses difficulties. Physicians are finding that they cannot provide patients the attention they deserve as they need to focus on entering data into the system during the encounter. Many rely on EMR-medical transcription integration. The physician uploads the dictation onto the medical transcription company’s secure server and these notes are directly entered into the EMR by the transcriptionists. This ensures the rapid production of quality transcripts and patient charting directly to the EMR, providing the physicians with more time and enhancing their patient evaluation capabilities.

Major Chiropractic Documentation Requirements for Medicare

MTS TEAM Chiropractic transcription

Chiropractors should understand the major chiropractic documentation requirements for Medicare as Medicare Part B covers chiropractic care under very limited circumstances such as: the treatment must be medically necessary while formally prescribed by a physician and the care must be provided by a Medicare-certified chiropractor. Coverage is given only to chiropractic treatment that involves the manipulation of the spine in order to correct a subluxation (a bone that is out of position in the spine). Though Medicare Part C Medicare Advantage managed care plan may cover slightly broader chiropractic treatment than Part B, a chiropractic service provided would be reimbursable through Medicare only if the documentation shows clinical necessity for that service. According to the American Chiropractic Association, the documentation for Medicare must include details of subluxation, initial and subsequent visits.

Requirements for Subluxation Documentation

There are two methods by which subluxation may be documented, such as X-ray and physical examination. If an X-ray is used for documentation, it must have been taken at a time that is reasonably proximate to the initiation of a course of treatment. An X-ray is regarded reasonably proximate if it was taken not more than 12 months before or three months following the initiation of the course of treatment unless more specific X-ray evidence is warranted. If physical examination is used, it must be documented as per the P.A.R.T system which includes four components such as:

P: PAIN AND TENDERNESS

This must be documented in terms of the location, quality, and intensity. It can be identified using one or more of the following:

Noting personal observation of pain that the patient exhibits during examination
Noting percussion, palpation, or provocation (if pain is reproduced while examining)
Asking patients to grade pain on a visual analog type scale from 0-10
Asking patients to verbally grade their pain from 0-10
Using pain questionnaires

A: ASYMMETRY/MISALIGNMENT

This may be identified on a sectional or segmental level by using one or more of the following:

Observing patient posture or gait analysis
Static and dynamic palpation
Diagnostic imaging (X-ray, CAT scan and MRI)

R: RANGE OF MOTION ABNORMALITY

This means documenting an increase or decrease in sectional or segmental mobility due to the changes in active, passive and accessory joint movements. It can be identified using one or more of the following:

Observing an increase or decrease in the patient’s range of motion
Noting motion palpation findings
Stress Diagnostic Imaging
Using motion measuring devices such as goniometers or inclinometers

T: TISSUE, TONE CHANGES

This represents alterations in the characteristics of contiguous and associated soft tissues such as skin, fascia, muscle, and ligament. It can be identified using one or more of the following.

Observing visible changes including signs of spasm, inflammation, swelling, and rigidity
Palpating tissues such as hypertonicity, hypotonicity, spasm, inflammation, tautness, rigidity, and flaccidity
Using instruments
Tests for length and strength

The instrument used and the finding should be documented well. In addition to this, leg length, scoliosis contracture, and strength of muscles must be documented.

According to the Centers for Medicare & Medicaid Services (CMS), at least two of these four components must be documented for Medicare reimbursement with at least one of A and R. As the carrier may request patient records at times, it is important to keep standardized patient chart notes.

Requirements for Initial Visit

While documenting for initial visit, make sure the following details are included:
History of the patient’s condition along with a detailed description of the present condition
Physical evaluation of musculoskeletal/nervous system
Diagnosis
Treatment Plan
Date of initial treatment

The treatment plan should include recommended level of care (duration and frequency of visits), specific treatment goals and objective measures to evaluate the effectiveness of the treatment.

Requirements for Subsequent Visits

History with review of chief complaint, improvement or regression since last visit and system review (if relevant)
Physical examination that include the exam of the spine that is involved in diagnosis, assessment of change in the patient’s condition since last visit and the evaluation of the effectiveness of the treatment
Details of treatment given on the day of visit
Changes to the treatment plan, if any

Even if you know about the documentation requirements, it is very important to use the common sense approach to Medicare documentation. This is because what seems to be appropriate for documenting one visit may not be sufficient for another while considering other factors such as frequency, duration of condition, severity of condition, and past history among others. If documentation becomes time-consuming for chiropractors and affect their productivity, they can always seek the support of professional transcriptionists to save time and effort.

Need for a Patient-centric Approach When Writing Pathology Reports

22-September-2014 Julie Clements Pathology Transcription

Pathology Reports Patient-centered care (sharing the management of an illness between the patient and the doctor) in general is very important for effective healthcare as it will increase adherence to management protocols, reduce morbidity and improve the quality of life of patients. The reason why patient-centered care is effective in pathology is that it helps patients understand their illness and participate in clinical decision-making through collaboration with the pathologists. However, this is possible only if patients can comprehend the pathology reports. This is why practices try to follow a patient-centric approach in such reports.

A 2014 study by a group of researchers at the University of Washington revealed that there is less adoption of patient-centered approaches in pathology reports. Most of the reports do not target patients as audience. It was also found that a significant number of patients lack the ability to comprehend this technical and complex document. The themes included in the proposed improvements in reports were content standardization, variation in terminology, clarity of communication and quality improvement. The study concluded that there are limited resources available to help patients comprehend the reports and efforts to enhance patient-centered communication are required to address this aspect of patient care.

Another study was published in 2014 by a group of American researchers, which evaluated the readability of pathology reports for common urologic cancers such as prostate, bladder, kidney, and testicular cancer to find out the sources of confusion that could be resolved through modified patient-centered reports. The study found that the reading levels of such reports are above the average reading capability of most American people. Though the removal of descriptive pathologic terms and the replacement of complex medical terminology with lay terms improved the readability for certain urologic oncology reports, it lessened the clarity of other reports.

The report that follows a patient-centered approach will include the patient’s chief concern or request, his/her illness experience, details about the disease (history of present past illness, review of systems, physical exam, laboratory exams and more), patient profile and individual life cycle phase, family history, genogram, culture and ecosystem, patient-doctor relationship, assessment, general discussion and proposed management plan. In short, pathology practices should adopt a patient-friendly approach while transcribing medical reports to ensure better patient care and improved patient satisfaction.

Nurses and PAs Can Ease Rheumatology Workforce Shortage

18-September-2014 Rajeev Rajagopal Rheumatology Transcription

A workforce study of rheumatology in the U.S. was conducted recently and it was revealed that the high demand for rheumatology services will cause a shortage of rheumatologists in the next several decades. A group of American researchers administered a nationwide survey of midlevel providers such as nurses and physician assistants (PAs) and found that they can alleviate the projected workforce shortage. The questions on demographics, level of practice, responsibilities, training, independence, use of objective outcome measures, drug prescribing, and knowledge and use of treat-to-target (TTT) strategies were included in the survey.

From the 174 responses, the researchers found three-quarters had less than or equal to 10 years of experience and around 53 percent received formal training in rheumatology care. The top three practice responsibilities of almost all respondents were providing patient education, adjusting medication doses and performing physical examinations. If two-thirds of respondents said they have their own panel of patients, majority of respondents were comfortable in diagnosing rheumatoid arthritis (RA) and had prescribed disease-modifying antirheumatic drug (DMARD). While three-quarters said they are using disease activity measures for RA, 56 percent reported their practices used TTT strategies. Since majority of respondents reported they had considerable expertise and adopted relevant strategies in their practice, the researchers suggest that midlevel providers may be able to help reduce workforce shortage.

Midlevel providers in rheumatology care should also ensure that their record keeping is going well for improved RA treatment and care. Electronic Health Records (EHRs) provide them with a number of advantages. The major benefits are:

Ability to set up alerts that can trigger certain tasks that might be overlooked. For example, some providers may accidentally leave the clinician chart sections that are not frequently used blank without drawing a line or writing ‘NA’. This may be considered as lack of proper documentation if there is a malpractice allegation. This problem can be solved by setting up alerts that insist clinicians complete the charts to close them.
Data within EHR can be used to measure multiple quality indicators for patients having RA such as the proportion of patients who were prescribed a DMARD, whether the patients have undergone appropriate laboratory testing prior to therapy, whether the patients were monitored for drug toxicity at the time of treatment and patient adherence to DMARD use.
Electronic prescribing (e-prescribing) is possible only with EHRs, which transfers prescriptions from paper order pads to an integrated electronic system that allows nurses, pharmacists, and other clinicians to access the full treatment plan, medication history, allergies, drug benefit coverage, and other pertinent information of patients at the point of care quickly using a computer or handheld device.

However, many nurse practitioners complain that clinical documentation is taking a long time with EHRs as there are endless loggings in and out, slow and cumbersome systems due to system failures, increased mandatory documentation and duplicate entries. They also struggle with the need to page through unnecessary screens and face difficulty finding where to chart something. Due to this, they are losing a good amount of time that should be dedicated to patients. Copying and pasting data within EHR is a good idea to save time. However, while the clinician copies and pastes data hastily to save time, there is more chance to perpetuate errors in the chart which will reflect on the entire digital record system and badly affect e-prescribing. Another complaint is that many practitioners find that EHRs require them to chart not only what they did, but what they didn’t do as well. Narrative description is also not possible with pre-defined templates and boxes.

A practical approach for nurse practitioners is to seek the support of transcriptionists to transcribe their dictations to produce a comprehensive and complete chart with reduced errors and populate the details into the digital record system using discrete transcription technology. This will save the time and effort of midlevel practitioners and at the same time improve the quality of treatment and care.